R.J. v. Certas Direct Insurance Company (19-009603)

The claimant sought payment for a housing accessibility assessment in excess of the $2,000 approved by the insurer, and sought a special award on cognitive training sessions that had been denied in 2017 but approved shortly before the hearing. Adjudicator Grant held that the $2,000 limit for assessments in section 25 applied to housing accessibility assessments, and that there was no carve out created by any Guidelines. He granted a special award of $200 on the cognitive training because the insurer had approved it shortly before the hearing, and had approved a similar treatment plan only months after denial of the subject treatment plan. The insurer had not set out a clear rationale for refusing the denied fees in the first place, and its approval of similar fees a few months later suggested that the fees were reasonable and necessary.